Lyndon Mason

Single-Photon-Emission Computed Tomography in Painful Total Ankle Replacements

Background: The use of single-photon-emission computed tomography (SPECT) in identifying unexplained pain in the foot and ankle has been described, where other imaging modalities have failed. The investigation of a painful total ankle replacement (TAR) is difficult, often not delineating a definitive cause. Our aim in this study was to investigate the use of SPECT-CT imaging in painful TARs. Methods: We performed a retrospective analysis of SPECT imaging performed for painful TARs in our department between October 2010 and December 2014. There were 14 patients identified who had undergone SPECT-CT imaging for a painful TAR. The mean age was 63.1 years, with a male/female sex ratio of 2:3 and a minimum time from surgery to imaging of 18 months. Results: Of the 14 patients, 13 were positive for increased osteoblastic activity in relation to the periprosthetic area consistent with implant loosening. The most common finding was tracer activity in relation to the talar component in 13 cases. There was additional tracer activity localized to the tibial component in 5 of these cases. In 10 of the 13 cases with prosthetic loosening/failure of bony ongrowth, there was no evidence of loosening on the plain radiographs. Infection was ruled out by using joint aspiration as clinically indicated. Conclusion: In our series, SPECT-CT imaging revealed a high incidence of medial sided talar prosthesis activity consistent with loosening. The finding of a high incidence of talar nonintegration illustrates the limitations of conventional radiology in follow-up of total ankle replacements, as this was not apparent on plain radiographs. We therefore conclude that there should be a high index of suspicion for talar prosthesis nonintegration in patients with otherwise unexplained ongoing medial pain in total ankle replacements. Level of Evidence: Level IV, retrospective case series.

Turf Toe and Disorders of the Sesamoid Complex

A turf toe injury encompasses a wide spectrum of traumatic problems that occur to the first metatarsophalangeal joint. Most of these injuries are mild and respond well to nonoperative management. However, more severe injuries may require surgical management, including presence of diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, loose body, and failed conservative treatment.

Chronic Achilles tendon rupture reconstructed using hamstring tendon autograft

BACKGROUND Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5-6 cm, especially if the distal stump is grossly tendinopathic. METHODS We describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy. RESULTS Patient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38-25, EQ5D-5L 18-9, EQ VAS 70-90 and VISA-A 1-64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded. CONCLUSION Reconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery.

Pathoanatomy and Associated Injuries of Posterior Malleolus Fracture of the Ankle

Background: We present a classification system that progresses in severity, indicates the pathomechanics that cause the fracture and therefore guides the surgeon to what fixation will be necessary by which approach. Methods: The primary posterior malleolar fracture fragments were characterized into 3 groups. A type 1 fracture was described as a small extra-articular posterior malleolar primary fragment. Type 2 fractures consisted of a primary fragment of the posterolateral triangle of the tibia (Volkmann area). A type 3 primary fragment was characterized by a coronal plane fracture line involving the whole posterior plafond. Results: In type 1 fractures, the syndesmosis was disrupted in 100% of cases, although a proportion only involved the posterior syndesmosis. In type 2 posterior malleolar fractures, there was a variable medial injury with mixed avulsion/impaction etiology. In type 3 posterior malleolar fractures, most fibular fractures were either a high fracture or a long oblique fracture in the same fracture alignment as the posterior shear tibia fragment. Most medial injuries were Y-type or posterior oblique fractures. This fracture pattern had a low incidence of syndesmotic injury. Conclusion: The value of this approach was that by following the pathomechanism through the ankle, it demonstrated which other structures were likely to be damaged by the path of the kinetic energy. With an understanding of the pattern of associated injuries for each category, a surgeon may be able to avoid some pitfalls in treatment of these injuries. Level of Evidence: Level III, retrospective comparative series.

Early Protected Weightbearing for Acute Ruptures of the Achilles Tendon: Do Commonly Used Orthoses Produce the Required Equinus?

&NA; Conservative “functional” management of acute Achilles tendon ruptures has become increasingly popular. Critical to this is the use of the walking orthosis, which positions the ankle in equinus to allow for early weightbearing. Our aim was to test whether 2 common orthoses achieved a satisfactory equinus position. A total of 11 sequentially treated Achilles tendon ruptures were assigned to either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus‐corrected brace (EEB). The lateral radiographs of the cast immobilized tendons showed a mean tibiotalar angle (TTA) of 56° (range 54° to 57°) and a mean tibio‐first metatarsal angle (1MTA) of 74° (range 62° to 85°). The FAWW resulted in a mean TTA of 28° (range 15° to 35°) and 1MTA of 37° (range 30° to 45°). The EEB resulted in a TTA of 48° (range 43° to 45°) and 1MTA of 54° (range 47° to 57°). Ankle equinus was significantly greater with the EEB than with the FAWW (p < .05) and similar to that with an equinus cast. The use of wedges produced an equinus appearance through the midfoot but not at the ankle. We express caution in the use of the FAWW because it is unlikely to achieve sufficient ankle equinus to shorten the Achilles tendon. &NA; Level of Clinical Evidence: 4

How Do I Use the Scarf Osteotomy to Rotate the Metatarsal and Correct the Deformity in Three Dimensions

The scarf osteotomy has become the workhorse procedure for a large proportion of foot and ankle surgeons, especially in Europe, in the treatment of hallux valgus. Such a versatile procedure should not be underestimated, and planning and thought should precede any such procedure. The angle of bone cuts and magnitude of translation dictate the final position, and all movement axes should be given equal attention.

Medial Approach to the Subtalar Joint

Surgical access to the subtalar joint is required in a plethora of pathologic conditions of the hindfoot. The conventional lateral approach can give excellent access to subtalar joint; however, in hindfoot valgus deformities, there can be unacceptable risks of wound problems and incomplete deformity corrections. The medial approach offers good access to the subtalar joint with an increasing evidence base for its use, especially with double fusions in pes planus deformities. The authors review the current evidence in the use of the medial approach for the subtalar joint.

Anatomy of the Lateral Plantar Ligaments of the Transverse Metatarsal Arch

Results: In all specimens, the long plantar ligament blended with a transverse metatarsal ligament spanning from the 2nd to the 5th metatarsal. This transverse metatarsal ligament formed the basis of the roof and distal aspect of the peroneus longus canal. The separate long plantar ligament formed the floor of the peroneus longus canal. In addition, separate intermetarsal ligaments were identifiable connecting each metatarsal. The long plantar ligament provides a connection through the transverse metatarsal ligament, connecting the transverse and longitudinal arches of the foot

Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

Introduction/Purpose: The treatment of posterior malleolar fractures is developing. Our previous study on the anatomy of the posterior malleolar fracture identified only 49% of rotational push off fractures of the posterior malleolus had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament insertion on the posterior tibia and its relation to push off fractures.

Fixation of Ankle Fractures: Experiences in Improving Quality

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most common fractures. Historically these have been frequently treated by non-specialists and junior staff. In 2011 we presented high malunion rates, which have been mirrored in other departments work. We present the results of system changes to improve the results of ankle fracture fixation Methods: Image intensifier films were reviewed on PACS and scored based on the criteria published by Pettrone et al. At least two blinded assessors assigned scores independently. Patients clinical data was collected from medical records. In 2011 we presented the results of fixation in 94 consecutive patients (Group 1) from 2009. Following this there was period of education in the department to allow change. 68 patients (Group 2) were then reviewed from a 7 month period in 2014 Multiple system changes were introduced in the department including; new treatment algorithms, dedicated foot and ankle trauma lists and clinics, and next day review of all intra-operative radiographs by independent attending. Prospective data was collected on 205 consecutive cases (Group 3) from 01/01/15 – 09/30/16 Results: Patients in group 1 had a malreduction rate of 33%. The major complication rate in this group was 8.5% (8 patients); with only one of these occurred in a correctly reduced fracture. These complications included 4 revision fixations, 2 deep infections and 1 amputation. Following the period of re-education, in Group 2, the mal-reduction rate deteriorated to 43.8%. In this group the major complication rate was 10.9%; including 6 revision fixations and 1 ankle fusion. In Group 3, following overall system changes, the malreduction rate was 2.4%. This result is statistically significant. The major complication rate fell to 0.98%; 1deep infection and 1 amputation (in a polytrauma patient with vascular injury). This result is again statistically significant. Conclusion: Our initial results show that very poor results are a consequence when sufficient attention is not given to what are frequently considered to be ‘simple’ fractures. In group 2 we demonstrated that soft educational changes (eg presentations, emails) are ineffective in improving results. We have demonstrated that hard (institutional system) changes in our department provided statistically significant improvements. These changes allowed the correct surgeon for the fracture in both determining the treatment plan and operating. With these changes, malreduction rates fell from 43.8% to 2.4% and major complication rates from 10.9% to 0.98%